1. JUDITH M. WILKINSON LESLIE S. TREAS KAREN BARNETT MABLE H. SMITH FUNDAMENTALS OF NURSING Copyright © 2016 F.A. Davis Company Chapter 31: Pain

2. Copyright © 2016 F.A. Davis Company What Is Pain? Unpleasant sensory/emotional experience Can have destructive effects Can warn of potential injury A multidimensional experience Whatever person experiencing it says it is; exists whenever person says it does Self-report always most reliable indication of pain

3. Copyright © 2016 F.A. Davis Company Classification of Pain By origin Superficial Visceral Somatic Radiating/referred Phantom Psychogenic

4. Copyright © 2016 F.A. Davis Company Classification of Pain (cont’d) By cause Nociceptive Neuropathic By quality By duration Acute Chronic Intractable

5. Copyright © 2016 F.A. Davis Company Acute Pain Major distinction from chronic pain is the effect on biologic responses Acts as warning sign Activation of sympathetic nervous system

6. Copyright © 2016 F.A. Davis Company Acute Pain Responses Increased heart rate Increased blood pressure Increased respiratory rate Dilated pupils Sweating

7. Copyright © 2016 F.A. Davis Company Chronic Pain Persists or recurs for indefinite period (more than 3 months) Onset is gradual Poorly localized (hard to pinpoint) Often accompanied by depression

8. Copyright © 2016 F.A. Davis Company Physiology of Pain Transduction: activation of nociceptors by stimuli Transmission: conduction of pain message to spinal cord Pain perception: recognizing and defining pain in cortex Pain modulation: changing pain perception

9. Copyright © 2016 F.A. Davis Company Chapter 3 Pain: The Fifth Vital Sign

10. Copyright © 2016 F.A. Davis Company Pain Transmission Painful stimuli often originate in extremities If pain not transmitted to the brain, person feels no pain Mu receptors otherwise activate Two specific fibers transmit periphery pain: – A delta fibers – C fibers

11. Copyright © 2016 F.A. Davis Company Pain Transmission (cont’d)

12. Copyright © 2016 F.A. Davis Company Factors That Influence Pain Past experience with pain Emotions Developmental stage Sociocultural factors Communication skills Cognitive impairments Other illnesses contributing to pain

13. Copyright © 2016 F.A. Davis Company Attitudes & Practices Related to Pain Health care provider and nurse attitudes affect interaction with patients experiencing pain Many patients reluctant to report pain – Desire to be “good” patient – Fear of addiction

14. Copyright © 2016 F.A. Davis Company Considerations for Older Adults Greater risk for undertreated pain Undertreatment of cancer pain due to inappropriate beliefs about pain sensitivity, tolerance, and ability to take opioids

15. Copyright © 2016 F.A. Davis Company Psychosocial Assessment All pain holds significant meaning for the person experiencing it Remain objective; advocate for proper pain control Unresolved pain leads to distrust – aberrant behaviors manifest – then withdrawal from routine activities – then depression sets in

16. Copyright © 2016 F.A. Davis Company Assessing Pain Includes Obtaining a complete pain history (e.g., onset, location, aggravating/alleviating factors) Nonverbal signs of pain Elevated pulse/blood pressure Crying, moaning Grimacing

17. Copyright © 2016 F.A. Davis Company PQRST for Pain Assessment P: Precipitating or palliative Q: Quality or quantity R: Region or radiation S: Severity scale T: Timing

18. Copyright © 2016 F.A. Davis Company Assessing Pain (cont’d) Pain scales Visual Analogue Scale (VAS) Numeric Rating Scale (NRS) Simple descriptor scale Wong-Baker Faces Pain Rating Scale

19. Copyright © 2016 F.A. Davis Company Pain Management Nonpharmacological measures Cutaneous stimulation Based on “gate control” theory Transcutaneous electrical nerve stimulation (TENS) Percutaneous electrical nerve stimulation (PENS) Acupuncture Acupressure Massage Use of heat and cold Contralateral stimulation

20. Copyright © 2016 F.A. Davis Company Pain Management (cont’d) Nonpharmacological measures (cont’d)  Immobilization and rest  Cognitive-behavioral interventions Distraction Progressive muscle relaxation Guided imagery Hypnosis Therapeutic touch Humor Journaling

21. Copyright © 2016 F.A. Davis Company Nonpharmacologic Interventions Used alone or with drug therapy Physical measures Physical and occupational therapy Cognitive/behavioral measures

22. Copyright © 2016 F.A. Davis Company Physical Interventions Complementary and alternative therapies Cutaneous stimulation – Application of heat, cold, pressure – Therapeutic touch – Massage – Vibration

23. Copyright © 2016 F.A. Davis Company Physical Interventions - TENS

24. Copyright © 2016 F.A. Davis Company Cognitive/Behavioral Measures Strategies used to relieve pain as adjuncts to drug therapy: – Distraction – Imagery – Relaxation techniques – Hypnosis – Acupuncture – Glucosamine

25. Copyright © 2016 F.A. Davis Company Invasive Techniques for Chronic Pain Used when drugs/other methods ineffective – Nerve blocks (temporary/permanent) – Spinal cord stimulation

26. Copyright © 2016 F.A. Davis Company Drug Therapy When nonpharmacologic methods are not helpful Administer before procedures (e.g., surgical debridement, complex dressing change) Three drug groups: – Non-opioids – Opioids – Adjuvants

27. Copyright © 2016 F.A. Davis Company Pain Management (cont’d) Pharmacological measures Nonopioid analgesics NSAIDs Acetaminophen Opioid analgesics Includes IV, transdermal, and epidural forms Client-controlled analgesia pumps

28. Copyright © 2016 F.A. Davis Company Analgesics by Classification: Non-Opioids Acetaminophen (Tylenol) NSAIDs (nonselective) – Aspirin, ibuprofen (Motrin), naproxen (Naprosyn, Alleve) NSAIDs (selective) – Celecoxib (Celebrex)

29. Copyright © 2016 F.A. Davis Company Analgesics by Classification: Opioids Pure agonists – Morphine long acting - MS Contin short acting – MSIR or instant release – Oxycodone long acting – OxyContin short acting – Oxycodone, OxyIR, “oxy” – Methadone – Codeine – Cocaine in terminaly ill – Fentanyl

30. Copyright © 2016 F.A. Davis Company Pain Pharmacologic Therapy— Opioid Analgesics Block release of neurotransmitters in spinal cord Suppress mu receptor activation Can be administered by every route PRN range orders Patient-controlled analgesia (PCA)

31. Copyright © 2016 F.A. Davis Company Side Effects of Opioids Nausea/vomiting Constipation Sedation Respiratory depression – late sign

32. Copyright © 2016 F.A. Davis Company Analgesics by Classification: Adjuvants SSRIs Anti-epileptic drugs (AEDs) Muscle relaxants/antispasmotic drugs Alpha-2 adrenergics Local anesthetics/analgesics NMDA antagonists Cannabinoids (cannabis extracts)

33. Copyright © 2016 F.A. Davis Company Considerations for Older Adults: Opioids “Start low and go slow”; initially use no more than half of recommended dose Evaluate patient response and drug effectiveness Older adults feel moderate and severe pain as much as younger adults

34. Copyright © 2016 F.A. Davis Company Community-Based Care Home care management Teaching self-management Health care resources

35. Copyright © 2016 F.A. Davis Company Special Nursing Considerations Managing pain in the elderly Managing pain in clients with addictions Use of placebos

36. Copyright © 2016 F.A. Davis Company Think Like a Nurse Which groups of patients are most at risk for inadequate pain management? What can you do to assist each group? How do past pain experiences affect present pain experience?